The End of Self-Referral?

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“The bottom line is that accreditation has the potential to have a tremendous impact on the delivery of imaging services in non-radiology physician offices,” said Tom Greeson in this afternoon’s session on MIPPA accreditation requirements. “Supervision can have a dramatic impact on the delivery of services paid for by Medicare and private payors.”

Greeson focused on the potential impact of accreditation and the Medicare anti-markup rule. The rule has been in the CMS regulations since the 60s, limiting the ability of those who purchased technical component services to markup and profit from those services. The way it’s structured today, the rule went into effect on January 1, 2009. “Every referring physician group in the country has been able to bill for their technical component services has been able to do so without triggering the rule,” he said. “How will accreditation impact that?”

Both the technical component and the professional component of all testing services must be billed by a physician who shares a practice with the billing physician. If the two physicians do not share a practice, the anti-markup rule is triggered. “I would submit that in the past eleven months every referring physician group in the country has been able to find some way to appear as if they share in the practice, and the reason for that is that there’s no accreditation requirement,” Greeson said. “There’s no obligation for that service to be supervised by anyone other than a physician who is an employee of that group practice or practices onsite.”

If the anti-markup rule is triggered, which Greeson says rarely happens, the referring physician group would be limited payment to the “net charge,” a nebulous concept that cannot include the cost of equipment or space. This means the payment would be pennies on the dollar.

At the moment, there is no proficiency requirement for the “supervising physician.” CMS defines proficiency as a physician who is proficient in the performance and interpretation of a diagnostic test – in other words, a radiologist. “Accreditation is looming in 2012,” Greeson said. “In my view, this is one of the most significant pieces of legislation ever adopted in terms of self-referral . . . if they do a couple of things.”

The anti-markup rule has been ineffectual so far because there are no accreditation requirements incorporated. But Greeson has his fingers crossed that this will change between now and 2012. Both ACR and RBMA recommended regular, documented onsite presence by general supervising physicians in the comments on CMS’ early version of the 2010 rule. Will this recommendation be implemented, creating a link between billing and accreditation and bringing about what Greeson calls “the end of self-referral”? We’ll have to wait and see . . .